Venous Thromboembolism

Reducing the Risk

<Name of session>
DATE
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Objectives
Define venous thromboembolism
Heighten awareness
the impact of VTE
the preventable nature of VTE

Discuss importance of
VTE risk assessment
appropriate prescribing of prophylaxis
engaging patients

Demonstrate how to assess VTE risk

Venous
Thromboembolism
VTE = Deep vein thrombosis (DVT) and/or
pulmonary embolism (PE)

DVT

PE

Occurs in deep veins

Occurs after DVT
(most commonly in legs dislodges and travels to
and groin)
the lungs
Can cause long-term
issues postthrombotic syndrome
(PTS)

Serious complication
which can lead to death

PTS affects 23-60% of

DVT patients within 2
years
Lower-extremity DVT
has 3% PE-related
mortality rate

Patients with PE have

30-60% chance of dying
from it

What Causes VTE

Virchows Triad = categories of
factors contributing to blood clot
Stasis
formation
Alteration in normal
blood flow

VIRCHOWS TRIAD

Endothelial
Injury
Injury or trauma to
the inside of the
blood vessel

Hypercoagulabili
ty
Alternation in the
constitution of blood
causing blood to clot
more easily

The Impact of VTE

More than 14,000
Australians
develop a VTE per
year
More than 5,000
of them will die as
a direct result
VTE causes 7% of
all hospital deaths

VTE causes more deaths than bowel Ca and breast Ca

VTE Risk Factors

VTE Risk Factors

Intrinsic Risk Factors

Extrinsic Risk Factors

Age > 60 years

Significantly reduced mobility

(relative to normal state) due to
injury or illness

Obesity (BMI > 30kg/m2)

Active malignancy or treatment

with chemotherapy

Prior history of VTE

Use of HRT or oral contraception

Pregnancy or post-partum

Surgical intervention,
particularly major orthopaedic
surgery or abdominal/pelvic
surgery for cancer

Known thrombophilia (including

inherited disorders)

Active infection

Varicose veins

Inflammatory bowel disease

Hospitalisation
Hospitalisation = risk of VTE
~ 50% of VTE cases occur
during or soon after
hospitalisation
24% (surgery)
22% (medical illness)

Incidence 100 times greater

in hospitalised patients
than community residents

Preventing VTE

Preventability
Largely preventable
Shift thinking: complication vs
adverse event
Risk
Assessme
nt

VTE
Preventi
on

Prescribin
g
Appropria
te
Prophylax
is

Assessing Risk
Who should be
assessed?

Others: Preadmission
for elective
surgery

ALL adult
patients
admitted
into hospital

Patie
nt
Grou
ps

Pregnant
and postpartum
women

Patients discharged
from ED with
significantly
reduced mobility
relative to normal
state
eg in a cast/boot
following lower leg
injury

Assessing Risk
Assess overall VTE risk vs benefit
Assess clotting risk
Assess bleeding risk
i.e. contraindications to
prophylaxis and/or other
bleeding risks

<indicate what tool is available at

your facility (State Tool* or Local
Tool)>

Prescribing Prophylaxis
Patient at risk + nil C/I = prescribe
Two types of prophylaxis:
1. pharmacological
2. mechanical
Ensure C/I to both pharmacological
and mechanical prophylaxis have
been considered
Evidence-based guidelines

NHMRC Guidelines

Pharmacological
Prophylaxis

Anticoagulants
Alter the process of
blood coagulation to
prevent VTE formation
The coagulation cascade and activity of
anticoagulants
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Pharmacological
Prophylaxis

Main anticoagulants include:

Drug Class

Agents

Unfractionat
ed heparin

Unfractionat
ed heparin

Preferred in patients with renal

impairment

LMWH

Enoxaparin
Dalteparin

Most commonly used agents

Require dosage adjustment in renal
impairment

Factor Xa
inhibitors

Apixaban
Rivaroxaban

Alternative for prophylaxis in post- hip

or knee replacement

Fondaparinu
x

Alternative for prophylaxis in post- hip

or knee replacement and hip fracture
surgery

Direct
thrombin
inhibitors

Dabigatran

Alternative for prophylaxis in

prophylaxis post- hip or knee
replacement

Heparinoid

Danaparoid

Used in heparin-sensitivity or HIT

Pharmacological
Prophylaxis

Contraindications may include:

Contraindications
Active bleeding
Thrombocytopenia (platelets < 50 x 109/L)
End stage liver disease (INR > 1.5)
Treatment with therapeutic anticoagulant e.g.
warfarin with INR > 2
Severe trauma to head or spinal cord, with
haemorrhage in last 4 weeks

Other relative contraindications may

exist weigh risk vs benefit

Mechanical Prophylaxis
Devices that increase blood flow
velocity in leg veins, reducing venous
stasis.
Device
They include:
Graduated
Compression
Stockings (GCS)

Provide graduated compression, which is

firmest at the ankle. Used mainly for
ambulant patients

Anti-embolic Stocking

Standard compression throughout.

Used for bedbound or non-ambulant patients

Intermittent
Pneumatic
Compression Device
(IPC)

Inflatable garment wrapped around legs

which is inflated by pneumatic pump.
Enhances venous return

Foot Impulse Device

(FID)

Stimulates legs veins to mimic walking and

reduce stasis. Used for immobilised patients

Mechanical Prophylaxis
Contraindications may include:
Contraindications
Skin ulceration
Lower leg trauma
Morbid obesity (where correct fitting of stocking
cannot be achieved)
Massive leg oedema or pulmonary oedema due to
CCF
Stroke patients (avoid compression stockings)

Other Ways to
Help Prevent VTE

Empowering Patients
Engage your patients

Questions

For further information:

stopclots@cec.health.nsw.gov.au
www.cec.health.nsw.gov.au